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From Reconstruction to Reproduction: Successful Pregnancy in Patients with Bladder Exstrophy a Single Institution Experience
Marjorie M. Johnson, MD1, Sohani K. Puranic, MBBS2, Erin Mayeux, MD1, Rafael Morales Grimany, MD1, Chad Crigger, MD3, John P. Gearhart, MD1, Heather N. Di Carlo, MD1.
1Johns Hopkins, Baltimore, MD, USA, 2ESIC Medical College Bangalore, Bangalore, India, 3Medical University of South Carolina, Charleston, SC, USA.
BACKGROUND: The earliest recorded case of a pregnancy in a patient with classical bladder exstrophy dates to the 18th century. This account described significant challenges during the patient’s delivery, underscoring the long-standing complexity of reproductive care in the exstrophy-epispadias complex (EEC) population. The objective of this study was to retrospectively review our institution’s large EEC database to better understand female reproductive outcomes in this population.
METHODS: Female patients over the age of 18 with classical bladder or cloacal exstrophy and a history of pregnancy (regardless of outcome) were included in this study. The primary outcome was achievement of pregnancy. Secondary outcomes evaluated included rate of live births, pregnancy losses, method of birth, method of bladder emptying, pelvic organ prolapse rates, need for additional urologic surgeries, urinary tract infections (UTIs), and obstetric complications.
RESULTS: Thirty-one patients met the inclusion criteria. These patients had a total of 57 pregnancies. Thirty-eight of these pregnancies (66.6%) resulted in live births of 40 children. Two pregnancies (3.5%) involved multiple gestations, both twins. There were 16 spontaneous abortions (28.1%), two ectopic pregnancies (3.5%), and one molar pregnancy (1.8%). Most deliveries occurred by cesarean section (78.9%), and both classical and low transverse incisions were utilized. Four patients (10.5%) delivered vaginally and four modes of delivery remain unknown. All patients underwent exstrophy closure during infancy, with 16 patients (51.6%) undergoing at least one osteotomy. Nine patients underwent at least one repeat exstrophy closure. Most patients emptied their bladder per urethra or via a stoma into a bladder augment. Eight patients experienced pelvic organ prolapse after delivery, and nine had UTIs during pregnancy.
CONCLUSIONS:Pregnancy is safe in those with bladder exstrophy. However, this population faces increased rates of pregnancy loss compared to national averages. While an exact cause remains unknown, the reason for increased pregnancy loss is thought to be multifactorial. The medical complexity of these patients highlights the need for lifelong multidisciplinary management.
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